Welcome to the MUS Webinar Controlled Drugs Gosport Then and Now - - PowerPoint PPT Presentation

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MEDICINES USE AND SAFETY WEBINAR OCTOBER 2019

• Welcome to the MUS Webinar – Controlled Drugs – Gosport Then

and Now

• The webinar itself will start at 1pm. Shortly before 1pm the SPS webinar host

will be doing sound checks so bear with us if you hear this more than once!

• To join the audio call 0203 478 5289 Access code: 952 783 486.
• The webinar will be recorded and both recording and slide set will be

available on the SPS website – under Networks (you need to be logged onto the SPS site to access the recording)

• If you want to make a comment or ask a question – please use the “chat”
• function. (You need to choose to direct your question to “All Participants”

from the drop down box)

• The presenters will answer questions at the end of the presentation

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Upcoming MUS Events

WEBINARS:

13 November Medicine Safety – 2020 and Beyond Sabina Khanom (NHSE/I), Nicola Wake (MUSN) 11 December Medicines Governance Do Once Programme Tracy Rogers, Jo Jenkins, Amanda Cooper FACE TO FACE EVENTS (held in London) 23 October MUSN (Fully booked) 27 November Older People Network

NHS England and NHS Improvement

The Gosport Independent Panel Report

jon.hayhurst@nhs.net

4 | 4 |

• Gosport is a town on a

peninsula in Hampshire

• Gosport and Portsmouth are

just a few hundred yards apart by ferry

• Separation is 15miles by road
• The hospital opened in 1923

and has developed as a community hospital

Gosport War Memorial Hospital

The Gosport Independent Panel Report

5 | 5 |

• Community hospitals vary considerably, as they have

adapted to the needs of their local populations

• In community hospitals, medical care is normally led

by GPs in liaison with consultants, nursing and other health professionals as required

• The pride of local people and their attachment to

Gosport War Memorial Hospital was illustrated by the successful campaign to save it from closure in the 1990s and indeed its redevelopment in 1994

Gosport War Memorial Hospital

The Gosport Independent Panel Report

6 | 6 |

• Concerns about the care of older patients in Gosport

War Memorial Hospital had been the subject of scrutiny for many years and numerous investigations had taken place

• In 2013, the Department of Health published a clinical

audit which had taken place in 2003 by Professor Richard Baker covering the period 1988-2000

• Norman Lamb established the Gosport Independent

Panel, under the chairmanship of Bishop James Jones, to review the documentary evidence

Concerns about care

The Gosport Independent Panel Report

7 | 7 |

• In February 1991 staff at Gosport expressed concern
• ver the prescribing and administration of drugs with

syringe drivers. A number of nurses raised concerns about the prescribing of drugs, in particular diamorphine.

• “A Staff Nurse at the hospital rang the local branch

convenor of the Royal College of Nursing to express concerns shared by other members of the night staff

• ver the use of diamorphine and syringe drivers.”

Concerns raised in 1991

The Gosport Independent Panel Report

8 | 8 |

The concerns

The Gosport Independent Panel Report

1. Not all patients given diamorphine have pain. 2. No other forms of analgesia are considered, and the ‘sliding scale’ for analgesia is never used. 3. The drug regime is used indiscriminately, each patients individual needs are not considered, that oral and rectal treatment is never considered. 4. That patients deaths are sometimes hastened unnecessarily. 5. The use of syringe driver on commencing diamorphine prohibits trained staff from adjusting dose to suit patients needs. 6. That too high a degree of unresponsiveness from the patients was sought at times. 7. That sedative drugs such as Thioridazine would sometimes be more appropriate. 8. That diamorphine was prescribed prior to such procedures such as catheterization – where diazepam would be just as effective. 9. That not all staff views were considered before a decision was made to start patients on diamorphine – it was suggested that weekly ‘case conference’ sessions could be held to decide on patients complete care.

• 10. That other similar units did not use diamorphine as extensively.

9 | 9 |

Raising the concerns in the first place was a brave act given the culture at the hospital. There is documented evidence that the nurses felt ostracised as a result. After an unsatisfactory meeting at which the nurses were faced with an intimidating array of other staff, evidence showed that the nurses were dismissively told to take any future concerns up directly with the doctor whose practice they had reason to challenge.

Culture

The Gosport Independent Panel Report

10 | 10 |

• It is over 27 year since nurses at the hospital first

voiced their concerns

• The report of the Gosport Independent Panel found

(in 2018) that the concerns were valid

Gosport Independent Panel

The Gosport Independent Panel Report

11 | 11 |

• It is over 27 year since nurses at the hospital first

voiced their concerns

• The report of the Gosport Independent Panel found

(in 2018) that the concerns were valid

• The lives of over 450 people (and probably

another 200 as well) were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital

Gosport Independent Panel

The Gosport Independent Panel Report

12 | 12 |

“For example, the daughter of one patient discovered that a syringe driver had been inserted. She queried this because she knew her father wasn’t in pain and didn’t need it, but ward staff were dismissive, telling her she was not a nurse and that they were the

• professionals. She was furious and called her

father’s GP, who arranged for the syringe driver to be taken out and for her father to come home.”

Patient stories

The Gosport Independent Panel Report

13 | 13 |

“Another patient was admitted for respite care but deteriorated and became confused during his stay. Staff asked permission to give him diamorphine, but his daughter refused, as he was not in pain. However, her mother later agreed, and he was started on diamorphine by syringe driver. He died the same day”.

Patient stories

The Gosport Independent Panel Report

14 | 14 |

“A man admitted for dementia was started on a diamorphine syringe driver. Staff asked his son for permission and he gave it but felt there was no explanation of what it meant to be given

• diamorphine. The dose was doubled, and his father

died five days later. His son felt that the diamorphine effectively killed him”.

Patient stories

The Gosport Independent Panel Report

15 | 15 |

• Finding One: Opioid usage without appropriate clinical indication
• Finding Two: Anticipatory prescribing with a wide range of doses
• Finding Three: Continuous opioid usage for patients admitted for

rehabilitation or respite care

• Finding Four: Continuous opioids started at inappropriately high doses
• Finding Five: Opioids combined with other drugs in high doses
• Finding Six: Few patients survived long after starting continuous opioids
• Finding Seven: Prescription and administration of drugs contravened

guidelines

• Finding Eight: Occurrence and certification of deaths

The panel’s findings

The Gosport Independent Panel Report

16 | 16 |

• Between 1987 and 2001, there was a huge increase

in the use of diamorphine without any apparent indication for the patients that received it

• At the same time there was a huge increase in the

number of deaths, and in the number of deaths being recorded as due to ‘bronchopneumonia’

• The patients involved were not admitted for end of

life care but often for rehabilitation or respite care

What exactly happened?

The Gosport Independent Panel Report

17 | 17 |

Opioids without indication

The Gosport Independent Panel Report

18 | 18 |

Deaths at the hospital

The Gosport Independent Panel Report

19 | 19 |

Deaths due to bronchopneumonia

The Gosport Independent Panel Report

20 | 20 |

Correlation

The Gosport Independent Panel Report

21 | 21 |

The practice of anticipatory prescribing, and of administering certain drugs in circumstances and doses beyond what would have been indicated or justified clinically, involved the consultants, the clinical assistant, the nurses and the pharmacists. Many people were prescribed and administered drugs that were not clinically indicated, in quantities sufficient to shorten their lives.

How did this happen?

The Gosport Independent Panel Report

22 | 22 |

Anticipatory prescribing was used on the basis that medication might become necessary at a time when the doctor covering a ward was unable or unwilling to attend in order to prescribe it. A pattern of clinical judgements were then being made that patients were close to death, regardless of the purpose of their admission or the plan in place. The documents show that these judgements were

• ften not justified clinically and did not take into

account patients’ or families’ views.

Why did this happen?

The Gosport Independent Panel Report

23 | 23 |

“It was some while later that I was to learn that all patients upon their admission were written up (by the doctor) who authorised the use of a syringe driver if

• appropriate. This enabled any member of the nursing

staff to set up a syringe driver for a patient without any further reference to the doctor.”

One account from staff

The Gosport Independent Panel Report, and the Government Response

24 | 24 |

“If one of the trained members of nursing staff considered that a patient required the use of a syringe driver then they would seek the approval of another trained nurse. Having reached agreement then the driver would be set up. I have witnessed disagreements between nurses where one of them did not agree that a patient required the use of a syringe

• driver. These disagreements would be resolved by the nurse

requiring the syringe driver approaching a more senior nurse and obtaining their consent. I have never known of a case where a staff member did not

• btain permission to use a syringe driver from senior staff.”

One account from staff

The Gosport Independent Panel Report

25 | 25 |

The culture at the hospital was a legacy of the concept of ‘clinical freedom’. In theory, this should have been entirely supplanted by evidence-based practice. There should have been an accepted practice of challenge, but this was not the prevailing culture. Indeed, in accepting the medical judgement made most often by the clinical assistant, the consultants effectively supported rather than challenged this practice, and the nurses were themselves involved.

Culture

The Gosport Independent Panel Report

26 | 26 |

Pharmacy services to the hospital were provided under a SLA with the Health Authority. This included the procurement and supply of medicines required, together with advice on their use, security and custody – a relationship described as ‘remote’.

Pharmacy services

The Gosport Independent Panel Report

27 | 27 |

• Police
• Health Authority
• Primary Care Group, and then Trust
• Department of Health
• General Medical Council
• Nursing and Midwifery Council

“No external organisation was able to intervene effectively”

Investigations

The Gosport Independent Panel Report

28 | 28 |

“Each organisation may have acted in its own interests and those of its leaders, motivated by reputation management, career self-preservation and taking the path of least resistance.” “The tendency of individuals in organisations, when faced with serious allegations [is] to handle them in a way that limits the impact on the organisation and its perceived reputation.”

Flawed investigations

The Gosport Independent Panel Report

29 | 29 |

“Organisations simply do not listen to what their frontline staff have to say. This is despite the fact that those members of staff see what is happening very clearly and can gauge its impact in practice, not least from engaging with members of the public, in this case patients and relatives.”

Take home messages

The Gosport Independent Panel Report

30 | 30 |

“If those responsible for the hospital had listened properly to what their own nurses said in 1991, and acted, the Panel is clear that the events described in this Report would not have followed the path they

• did. This should serve as a challenge to all those in

positions of authority.”

Take home messages

The Gosport Independent Panel Report

NHS England and NHS Improvement

The Gosport Independent Panel Report

jon.hayhurst@nhs.net

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The DHSC response

The response addresses policy and systems issues and describes 3 types of action:

• Measures already in place - CD regime
• Reforms in place but developing - Freedom to speak up
• Changes where we need to go further - improved / more aligned

investigation ref Operation Magenta (Eastern Police Region)

• Plus describes the work by some national organisations and

services to identify and apply lessons from the Panel report

• 3 key areas identified for action

​

Listening to patients, families and staff

• Support & protection for whistle-blowers
• The importance of speaking up / concerns to be investigated
• CQC is reviewing how it assesses Duty of Candour
• Listening & learning from feedback to improve care

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Ensuring care is safe

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• NHSE to review the CDAO role / local reflection on the Panel

report & anticipatory prescribing

• Continued implementation and support for Learning from

Deaths programme and Medical Examiner for non- coronial deaths

• A new Patient Safety strategy
• Areas of note: isolated practice / syringe drivers

Ensuring care is safe

NHSE initiated the following actions:

• A review of the governance and leadership of

the NHSE CDAO role

• A review of the operation of the NHSE lead CDAOs including

the effectiveness of CDLINs

• An assurance process to assess how designated bodies reflect
• n learning from the panel report
• An assurance process on the appropriateness of anticipatory

prescribing.

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Identifying and addressing problems in care

• CQC review of external oversight
• Responding to feedback
• Assessment around medicines
• NHSE & NHSI joint oversight of quality
• Government commitment - framework of professional regulation
• GMC - senior patient champion
• NMC - Public support service / identify key learning
• GPhC - to review work with other pharmacy representative bodies
• Appointment of a National Medical Examiner
• Revision of NHS serious incident framework

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Identifying and addressing problems in care

• Government commitment to investigatory processes
• Ministry of Justice to refresh its guide to Coroner Services to better tailor

to bereaved families

• Government commitment to establish an Independent Public Advocate

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Response conclusions

• The report acts both as a warning and a call to action
• All organisations MUST continue to reflect and do all they can to prevent

a future failure of this nature.

• The need to avoid complacency

Some things to consider going forward:

• More governance and more guidance in place

Legislation / SOPs / CDAOs / LINs / MSOs / Guidance BUT

• Complex commissioning arrangements - potential gaps in oversight
• End of life care - now more than ever managed in the community
• On-going fast changing health care landscape

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CDLIN effectiveness survey

• Undertaken by CQC on behalf of NHS England to look at the

effectiveness of their Controlled Drugs Local Intelligence Networks (CDLINs).

• Survey ran from 1st April until 7th May 2019.
• Received 481 complete anonymised survey responses.
• Formal response returned to NHS England in August 2019.

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How beneficial do you consider the LIN in securing the safe management and use of controlled drugs?

(1 being lowest 5 being highest).

How confident are you in sharing sensitive information with LIN members about concerns? How effective do you consider the LIN is at taking action? How effective do you consider the LIN is at facilitating the co-

• peration?

CDLIN effectiveness survey​

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What could the LIN do differently, what should it stop doing and is there anything it should start doing?” Summary of free text answers.

Reporting

• Request meeting updates before

CDLIN takes place.

• A consistent approach to which

incidents to report.

• Need clarity at what level of risk to

report to CDAO for the quarterly report.

• Don’t see the point in submitting

reports on line, should be able to access DATIX incident reports.

• Private sector providers do not share

incident reports and when they do they tend to gloss over events, perhaps in case it proves commercially damaging.

• The reporting in occurrence reports is

not presented in any consolidated view to identify signals. CDLIN content

• Include an element of education.
• Clear meeting objectives/outcomes.
• Better workload balance – all weighed
• n designated bodies.
• Focus on real issues of concern and

not every CD incident.

• Be more pro-active about certain issues

rather than re-active.

• Providing feedback and results from

discussed investigations.

• Less time spent on public health issues.
• Hold organisations to account for their

lack of systems and processes they have in place.

• Add a section for prior submitted

questions that are answered at the LIN.

• It may be helpful to additionally receive

feedback at the learning and sharing LIN meetings from CQC around CD issues and ongoing work from the CD working groups.

• More focus on Primary care prescribing

and community management of CDs. Location  Local CDLINs for local

• rganisations.

 Members to be able to attend

• ther CDLINs outside their
• wn.

 Too big a geography, trying to blend geographical areas together that have little in common re patient flow. Membership The effective LINs are smaller, so everyone feels free to speak. Inviting community service providers, pharmacy reps, GPs, and PCN Rep Perhaps the CDAOs for larger

• rganisations would benefit from

their MSOs attending as well/instead. Established providers with history.

CDLIN effectiveness survey​

RPS discussion paper

• RPS paper: advised by its Hospital Expert Advisory Group
• How pharmacy services have developed since Gosport:
• Person-centred pharmacy practice
• Assurance processes / CDAOs / GPhC / MSOs / system regulators

/ CDLINs / electronic tools

• The RPS professional standards for hospital pharmacy services
• The standards provide a framework for all providers of pharmacy

services (NHS or independent sector) whether provided in-house or

• utsourced.
• They describe what is expected of a quality pharmacy service.
• Organisations delivering or commissioning services in line with the

standards will have a level of assurance that the services are safe, effective and patient-focused.

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RPS discussion paper

• Standard 2 Episode of Care: Treatment requirements are clinically

reviewed to optimise outcomes from any medicines prescribed; frequency and level of review adjusted according to patient need.

• Standard 4 Medicines governance: The pharmacy team actively works

with, and where necessary intervenes with prescribers, patients and

• ther healthcare professionals to ensure medicines are safe and

effective

• Standard 6 Leadership: All members of the pharmacy team are

encouraged and supported to raise any professional concerns they may have both from within the pharmacy service, and from other parts of the

• rganisation

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RPS discussion paper: Areas for Action

• Reinforce the importance of a culture that encourages challenge of

unsafe practice

• Review training / learning/ staff surveys
• Review against national best practice
• Review governance / benchmark / challenge unusual use
• Utilise tools / digital systems
• Look at all hospital deaths were opioids were prescribed.
• Audits of practice against organisation guidelines for palliative care and

pain guidelines.

• Audit of the volume of high strength opioid vials and limited stock

availability in clinical areas.

• Annual review of patient safety incidents involving opioids to promote

shared learning and identify trends.

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A SHORT INTERLUDE……

While we collate your questions, we would be really pleased if you could complete a 1 minute poll which will appear on your screen. This will help us know how we are doing! The questions are: To what extent was this event useful to you? If this webinar was repeated, would you recommend it to your colleagues. THANK YOU – NOW, ON TO YOUR QUESTIONS AND ANSWERS!

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Questions?

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Upcoming MUS Events

WEBINARS:

13 November Medicine Safety – 2020 and Beyond Sabina Khanom (NHSE/I), Nicola Wake (MUSN) 11 December Medicines Governance Do Once Programme Tracy Rogers, Jo Jenkins, Amanda Cooper FACE TO FACE EVENTS (held in London) 23 October MUSN (Fully booked) 27 November Older People Network